GW1--04897_Well Construction - GW1_20240828

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Er l;< Sanderson 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
2 n 27.E 3s f ft.
�° ft-
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER(if ap licable)
FROM TO DIAMETER THICKNESS MATERIAL
.5014derso4s w el/ A rill; 13 0 ft. 35 ft. I '/y -1 pMc
Company Name
2.Well Construction Permit#: �0g90 2 w 3 16.INNER CASING OR TUBING(geothermal clos -loop)
FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.(JIG,County.State,Variance,etc.) ft- ft. in.
3.Well Use(check well use): ft. ft. iD'
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKN MATERIAL
Agricultural OM al/Public 3C ft. 7/0 ft / / pi, __
Geothermal(Heating/Cooling Supply) esidentiai Water Supply(single) ft ft, i in.
Industrial/Commercial ()Residential Water Supply(shared)
18.GROUT
Irrigation FROM TO MATE L EMP CCEMENT METHOD&AMOUNT
Non-Water Supply Well: 0ft. .21-.1 ft' :�Slr.F (.."Pei.,4y
Monitoring Recovery f. ft
Injection Well:
ft. ft.
Aquifer Recharge OGroundwater Remediation 19.SAND/GRAVEL PACK(if applicable)
Aquifer Storage and Recovery 0Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test DStormwater Drainage ft ft.
Experimental Technology 0Subsidence Control ft. ft.
Geothermal(Closed Loop) ()Tracer 20.DRILLING LOG(attach additional sheets if necessary)
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soil/rocktype,Brain size,etc.)
,,/ 0 ft >v ft. . a viy GA j yet. fit
4.Date Well(s)Completed:Q .3/2 .2y Well DM 10 ft j ft 1 e Yell f+."a greet r.1 ,5yn 1/
5a.Well Location: 20 ft' 30 ft L/izt. CAr /Ai S. 4
R° °' V4Il e ' 0 30 ft. "to ft- resob ct4/ j `54,1 d
Facility/Owner Name Facility ID#(if applicable) ft ft / r- f "'t
F/Sher Rd Sf A,,IL ft. ft. ,' , ._,
Physical Address,City.and Zip ft ft. AUG 2 S 2024
D_ i eC^n te r2
'3O// /lQ'O f 4DO p 21.REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one/lat/long is sufficient) 22.Certification:
3q(' zi %747 ' N 7g'S?, ?92" w _E,fretc -,,, Og/23/-2)e
6.Is(are)the well(s) - Permanent or Temporary Signature of Certified Well Contractor Date
By signing this form,I hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: DYes or Er with I SA NCAC 02C.0100 or iSA NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fill out known well construction information and explain the nature of the copy of this record has been provided to the well owner.
repair under#21 remarks section or on the back of this form.
23.Site diagram or additional well details:
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You may use the back of this page to provide additional well site details or well
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: O (ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3@200'and 2@100) construction to the following:
10.Static water level below top of casing: / 3 (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: S. (in.) 24b.For Injection Wells: In addition to sending the form to the address in 24a
above, also submit one copy of this form within 30 days of completion of well
12.Well construction method: /ztar f/ construction to the following:
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) S Method of test: Atr///ii/y 24c.For Water Supply&Injection Wells: In addition to sending the form to
f the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: iN 7 /' Amount: 5- 5 fa 41s completion of well construction to the county health department of the county